Endoscopic Transpapillary Research Articles

Current Status in the Treatment of Acute Cholecystitis Patients Receiving Antithrombotic Therapy: Is Endoscopic Drainage Feasible?- A Systematic Review.

The bleeding complication risk of surgery or percutaneous transhepatic gallbladder drainage (PTGBD) may increase in patients with acute cholecystitis receiving antithrombotic therapy (ATT). Endoscopic gallbladder drainage (EGBD) may be recommended for such patients. English articles published between 1991 and 2018 in peer-reviewed journals that discuss cholecystectomy, PTGBD, and EGBD in patients with ATT or coagulopathy were reviewed to assess the safety of the procedures, especially in terms of the bleeding complication. There were 8 studies on cholecystectomy, 3 on PTGBD, and 1 on endoscopic transpapillary gallbladder drainage (ETGBD) in patients receiving ATT. With respect to EGBD, 28 studies on ETGBD (including 1 study already mentioned above) and 26 studies on endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) were also analyzed. The overall bleeding complication rate in patients with ATT who underwent cholecystectomy was significantly higher than that in patients without ATT (6.5% [23/354] vs. 1.2% [26/2,224], p<0.001). However, the bleeding risk of cholecystectomy and PTGBD in patients receiving ATT was controversial. The overall technical success, clinical success, and bleeding complication rates of ETGBD vs. EUS-GBD were 84% vs. 96% (p<0.001), 92% vs. 97% (p<0.001), and 0.65% vs. 2.1% (p=0.005), respectively. One patient treated with ETGBD experienced bleeding complication among 191 patients with bleeding tendency. ETGBD may be an ideal drainage procedure for patients receiving ATT from the viewpoint of bleeding, although EUS-GBD is also efficacious.

Mechanisms and prevention of biliary stent occlusion

One of significant achievements of modern endoscopy is development of retrograde biliary stenting for obstructive jaundice. This method ensured widespread application of endoscopic decompression in the treatment of patients with malignant biliary obstruction as preparation before radical surgery and final palliative care. Endoscopic retrograde transpapillary stenting firmly took its place together with antegrade and percutaneous stenting. There are certain advantages of this technique including minimally invasiveness and favorable quality of life. However, this approach is associated with some drawbacks associated with stent occlusion and difficult correction of this complication. The maximum diameter of the plastic stent (PS) is determined by the width of the working channel of the duodenoscope. In this regard, self-expandable metal stents (SEMS) were developed to increase the diameter of bile drainage channel. SEMS are associated with prolonged function. However, there is another problem. It is a germination of SEMS followed by impossible removal of the stent for its subsequent replacement. A further step in development of endoscopic biliary stents was the use of special SEMS coating to exclude tumor or granulation ingrowth. The problem of biliary stent occlusion remains relevant despite some improvement of stenting results. Mechanisms of occlusion of biliary stents and prevention of these events are discussed in this review.

Feasibility of endoscopic ultrasound-guided gallbladder drainage for acute cholecystitis patients receiving antithrombotic therapy.

Background:Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) as a treatment for patients with acute cholecystitis has been shown to obtain high technical and clinical success rates and a low recurrence rate. However, the safety of EUS-GBD for patients receiving antithrombotic therapy (ATT) has not been proven. The aim was to evaluate the safety and efficacy of EUS-GBD in patients receiving ATT.Methods:Twelve patients with acute cholecystitis associated with gallstones who were receiving antithrombotic therapy and underwent EUS-GBD were enrolled in this retrospective study. Patients with grade II or III cholecystitis who had failed endoscopic transpapillary GBD (ETGBD) or developed recurrence after multiple ETGBD procedures underwent urgent drainage by EUS-GBD. The primary outcome was the rate of bleeding complications after the procedure and the secondary outcomes were the technical and clinical success rates, complications, and recurrence.Results:Eleven (91.6%) patients underwent EUS-GBD with continuation of ATT (at least 1 agent). Five of 12 patients (41.7%) were receiving more than 1 agent for ATT. The rate of bleeding complications was 0% and the technical success rate was 100%, even though some patients had high-grade (severe) cholecystitis and/or several underlying diseases. Early complications were found in 2 (16.7%) patients. The clinical success rate was 91.7% (11/12). There were no recurrences of cholecystitis during the follow-up period (mean 261 [range 5-650] days).Conclusions:EUS-GBD yielded high technical and clinical success rates and a low recurrence rate. No patients receiving ATT developed bleeding complications. EUS-GBD might be a good option for patients on ATT.

A New Technique of Endoscopic Transpapillary Gallbladder Drainage Combined with Intraductal Ultrasonography for the Treatment of Acute Cholecystitis.

Background/Aims:Endoscopic transpapillary gallbladder drainage (ETGBD) is useful for the treatment of acute cholecystitis; however, the technique is difficult to perform. When intraductal ultrasonography (IDUS) is combined with ETGBD, the orifice of the cystic duct in the common bile duct may be more easily detected in the cannulation procedure. The aim of this study was to evaluate the efficacy of ETGBD with IDUS compared with that of ETGBD alone. Methods:A total of 100 consecutive patients with acute cholecystitis requiring ETGBD were retrospectively recruited. The first 50 consecutive patients were treated using ETGBD without IDUS, and the next 50 patients were treated using ETGBD with IDUS. Through propensity score matching analysis, we compared the clinical outcomes between the groups. The primary outcome was the technical success rate. Results:The technical success rate of ETGBD with IDUS was significantly higher than that of ETGBD without IDUS (92.0% vs. 76.0%, p=0.044). There was no significant difference in procedure length between the two groups (74.0 min vs. 66.7 min, p=0.310). The complication rate of ETGBD with IDUS was significantly higher than that of ETGBD without IDUS (6.0% vs. 0%, p<0.001); however, only one case showed an IDUS technique-related complication (pancreatitis). Conclusions:The assistance of IDUS may be useful in ETGBD.

Endoscopic ultrasound-guided gallbladder drainage, transpapillary drainage, or percutaneous drainage in high risk acute cholecystitis patients: a systematic review and comparative meta-analysis.

Endoscopic transpapillary gallbladder drainage (ETGBD) and endoscopic ultrasound-guided gallbladder drainage (EUSGBD) are alternatives to percutaneous gallbladder drainage (PCGBD) for patients with acute cholecystitis who are unfit for surgery. Data comparing these modalities are limited and have reported conflicting results. We searched multiple databases from inception to May 2019 to identify studies that reported on ETGBD, EUSGBD, and PCGBD in the management of acute cholecystitis in patients with a high surgical risk. Aims were to compare the pooled rates of technical success, clinical success, adverse events, and disease recurrence. 1223 patients (22 studies), 557 patients (14 studies), and 13 351 patients (46 studies) were treated by ETGBD, EUSGBD, and PCGBD, respectively. The pooled technical and clinical successes were: ETGBD 83 % (95 % confidence interval [CI] 80.1 - 85.5, I 2 = 29) and 88.1 % (95 %CI 83.6 - 91.4, I 2 = 50), respectively; EUSGBD 95.3 % (95 %CI 92.8 - 96.9, I 2 = 0) and 96.7 % (95 %CI 94.0 - 98.2, I 2 = 0), respectively; and PCGBD 98.7 % (95 %CI 98.0 - 99.1, I 2 = 0) and 89.3 % (95 %CI 86.6 - 91.5, I 2 = 84), respectively. Clinical success with EUSGBD was significantly superior to the other approaches. All complications were comparable between the groups. Pancreatitis occurred with ETGBD in 5.1 % (95 %CI 3.5 - 7.3), whereas bleeding and perforation occurred with EUSGBD in 4.3 % (95 %CI 2.7 - 6.8) and 3.7 % (95 %CI 2.3 - 6.0), respectively. Stent migration occurred with PCGBD in 7.4 % (95 %CI 5.5 - 10.0). EUSGBD demonstrated better clinical success than ETGBD and PCGBD in the management of acute cholecystitis patients at high surgical risk.

The "zipline" technique for endoscopic transpapillary biliary biopsy.

The "zipline" technique for endoscopic transpapillary biliary biopsy.

905 Endoscopic Ultrasound vs. Endoscopic Trans-Papillary vs. Percutaneous Gallbladder Drainage in High-Risk Acute Cholecystitis Patients: A Systematic Review and Indirect Comparative Meta-Analysis

INTRODUCTION: Endoscopic transpapillary gallbladder drainage (ETGBD) and endoscopic ultrasound guided gallbladder drainage (EUSGBD) are alternative to percutaneous gallbladder drainage (PCGBD) in the management of acute cholecystitis in patients deemed unfit for surgery. The role of endoscopy in the treatment algorithm has not been confirmed due to limited data and conflicting results. METHODS: We searched multiple databases from inception through May2019 to identify studies that reported on ETGBD, EUSGBD, and PCGBD in the management of acute cholecystitis in patients high-risk for surgery. Our goals were to indirectly compare the pooled rates of technical success, clinical success, adverse events, and disease recurrence with ETGBD, EUSGBD, and PCGBD by meta-analysis methods. RESULTS: 15131 patients from 72 studies were analyzed. 22 studies (1223 patients), 14 studies (557 patients), and 46 studies (13351 patients) were treated by ETGBD, EUSGBD, and PCGBD respectively. The pooled technical and clinical successes of EUSGBD were statistically superior to ETGBD [95.3% (95%CI 92.8-96.9, I2 = 0) vs 83% (95%CI 80.1-85.5, I2 = 29), P = 0.001] and [96.7% (95% CI 94-98.2, I2 = 0) vs 88.1% (95%CI 83.6-91.4, I2 = 50), P = 0.001], respectively. Pooled clinical success with EUSGBD was statistically superior to PCGBD [89.3% (95%CI 86.6-91.5, I2 = 84), P = 0.001]. The pooled rate of disease recurrence was comparable between ETGBD and EUSGBD, but more with PCGBD (10.8%, 95%CI 8.4-13.9, P = 0.001). The pooled rate of all adverse events were comparable between the groups (Table 1). Bleeding and perforation was statistically more with EUSGBD [4.3% (95%CI 2.7-6.8), P = 0.03; 3.7% (95%CI 2.3-6), P = 0.004; respectively], pancreatitis was statistically more with ETGBD [5.1% (95%CI 3.5-7.3, P = 0.003], and stent-migration was more with PCGBD 7.4% (95%CI 5.5-10, P = 0.01) (Table 2). All cause mortality was 9.8% (7.7-12.4) with PCGBD and was statistically significant when compared to EUSGBD (3.8%, 2-7, P = 0.006). CONCLUSION: This is the largest and most comprehensive meta-analysis indirectly comparing ETGBD, EUSGBD and PCGBD in the treatment of acute cholecystitis in surgically unfit patients. Based on our analysis, EUSGBD demonstrates superior clinical success when compared to ETGBD and/ or PCGBD, albeit with increased risk to perforation and bleeding. Given the low heterogeneity and the strength of the data, EUSGBD should be considered the first line approach in this patient population.

Antegrade lithoextraction as perspective rechnique for mechanical jaundice radical treatment

Material and methods From 2014 to 2017 in our hospital 1158 patients with cholelithiasis complicated by mechanical jaundice have been treated. The group consisted of 59 (5.1%) patients with initially predicted difficulties for endoscopic lithoextraction. In 12 of that group antegrade decompression was the only surgical method for completing treatment. In 2 cases the ‘rendezvous’ technique was used, and in 23 patients the antegrade decompression it was complemented with laparotomy and choledocholithotomy. In 22 patients for verification the nature of the bile-excreting ducts and the cholelithic occlusion revealed at the same time the first stage included an antegrade decompression that allowed to finish surgical treatment by an endoscopic transpapillary lithoextraction.Results In the main group of clinical observations for 59 patients the surgical treatment complemented with an antegrade decompression was without fatal outcomes. All patients were cured of cholelithic occlusion and recovered. In the study group with 1099 patients that were treated with only an endoscopic lithoextraction 8 patients died that showed 0.7±0.2% of operational mortality. Complications, in the form of operational wounds in the main group of observations were found in 7 patients and it was 11.8±4.2%. Other postoperative complications in the main group were not observed. In the control group similar wound complications were seen in 13 patients (1.2%). In the control group with 57 patients we observed intraabdominal complications which resulted in mortality (5.2±0.7%). Of those postoperative reversible pancreatitis was found in 34 patients, 3 patients had fulminant pancreonecrosis, in 4 cases there was profuse bleeding from a papillosphincterotomy area, in 3 cases we observed insertion of Dormia basket at lithoextraction, septic cholangitis was in 11 and duodenum perforation with retroperitoneal phlegmon was in 3 cases.Conclusion Mortality in the group with antegrade treatment application for choledocholithiasis was not found. On the contrary, rather higher rate of complications in the control group testifies in advantage of the antegrade techniques for choledocholithiasis treatment in the shown cases.

Features of surgical tactics in acute cholangitis depending from the mechanism of its development

Purpose of the study. Improvement of acute cholangitis treatment by improving surgical tactics, depending on the mechanisms of acute cholangitis development.&#x0D; Materials and methods. Analysis of 135 patients with gallstone origin acute cholangitis. In 18 (13,3%) of these patients, acute cholangitis was accompanied by acute destructive cholecystitis; in 7 (5,2%) cholangitis was complicated by liver abscesses formation. Endoscopic transpapillary intervention was performed on 132 (97,8%) patients, and laparoscopic operations – 105 (7,8%). Totally, among 135 patients were 248 stages of surgical treatment. One-stage treatment for cholangitis was performed in 33 patients, 2 stage – 91 patients, and three stages – 11 patients.&#x0D; Results. Complications after endoscopic and laparoscopic interferences occurred in&#x0D; 17 (12,6%) patients. Complications after endoscopic interventions were bleeding from papilla – 4, acute pancreatitis – 3; after laparoscopic interventions – inflammatory complications of postoperative wounds – 6, conversion – 5. Died 2 (1,5%) patients, the cause of death in both cases was sepsis.&#x0D; Conclusion. The ascending and bladder mechanisms of acute cholangitis development with cholelithiasis require a different sequence of stages of endoscopic transpapillary and laparoscopic surgical interventions. Differentiated tactics, depending on the cause of acute cholangitis, contribute to reducing the trauma of surgical treatment and improving its results.

Local instilation of antibiotics through nasocystic catheter for the treatment of infected pancreatic necrosis: Can necrosectomy be avoided?

Pseudoaneurysms associated with pancreatic pseudocysts are different from simple, isolated pancreatic pseudoaneurysms and there is paucity of published data on their non surgical treatment.To retrospectively analyze results of combination of angioembolisation or thrombin injection followed by endoscopic transpapillary drainage for management of pseudoaneurysms associated with pancreatic pseudocysts.Eight patients (all males; mean age ± SD: 31.2 ± 6.1 years; age range: 21–38 years) underwent radiological management of the pseudoaneurysm followed by endoscopic drainage of the pseudocysts.All patients had pseudocysts (median size 4 cm) with underlying chronic pancreatitis. All patients had abdominal pain on presentation and 7/8 (87.5%) patients had presented with overt gastrointestinal bleeding. The size of the pseudoaneurysms varied from 1 to 4 cm. Two patients were treated with percutaneous thrombin injection whereas six patients underwent digital subtraction angiography and angioembolisation. All patients underwent successful endoscopic transpapillary drainage through the major (5) or minor papilla (3) and resolution of pseudocysts was noted within 6 weeks (median 4 weeks). No significant complication of the procedure was noted in any of the patients.Pseudoaneurysms associated with pancreatic pseudocysts can be successfully and safely treated with a combination of radiological obliteration of the pseudoaneurysm followed by endoscopic transpapillary drainage.

Endoscopic transpapillary gallbladder stenting using a newly designed plastic stent for acute cholecystitis.

Abstract Background and study aims Biliary plastic stents are generally substituted for gallbladder stents in endoscopic transpapillary gallbladder stenting (EGBS), there is no sufficient evidence about what type of plastic stent is suitable. We examined outcomes of EGBS using standard biliary stents and a novel stent for acute cholecystitis and evaluated the efficacy of the novel stent. Patients and methods Seventy patients with acute cholecystitis in whom EGBS was performed were evaluated retrospectively. We performed EGBS in 23 patients using the novel stent (novel stent group) and 47 patients using standard biliary stents (pigtail: 35, straight: 12) (control group). In the two groups, we examined outcomes of EGBS. Results There were no significant differences in patient backgrounds or rates of technical success, clinical success, or early adverse events (AE) between the novel stent group and the control groups. However, rates of late AEs were 4.3 % in the novel stent group (liver abscess: 1) and 40.4 % in the control group (stent migration: 15, recurrence of cholecystitis: 4), indicating a significantly higher rate in the control group (P = 0.004). The rate of stent migration was significantly higher in the control group (P = 0.006). Multivariate analysis identified a straight type stent as the risk factor for stent migration (odds ratio: 8.81, 95 % confidence interval: 1.66 – 46.83). Conclusions The novel stent had significantly lower rates of late AEs and stent migration. Thus, for long-term stent placement, the novel stent was more effective than traditional biliary stents.

GALLBLADDER WALL CONDITION IN THE LONG-TERM AFTER ENDOSCOPIC TRANSPAPILLARY INTERVENTIONS

The aim of research. Study changes in the gallbladder wall in the long-term (more than 7days) after endoscopic transpapillary interventions on the common bile duct.Material and methods. Preparations of the 29 gallbladder wall, operatively removedmore than 7 days after endoscopic transpapillary interventions on the common bile ductwere painted with hematoxylin-eosin and pyrofuksin by Van Gison, the thickness ofmechanically strong structures (muscle layers, collagen) and mechanically weakstructures (intermediate edema, areas of necrosis, areas of leukocyte infiltration) of thegallbladder wall.Results. In terms more than 7 days after endoscopic transpapillary surgical interventionthe following types of changes in the gallbladder wall: "infiltrative sclerotic" and"restorative" were revealed. Basically, collagen structures and leukocyte infiltration havebeen detected in the period from 7 to 18 days following endoscopic transpapillaryintervention on the common bile duct in the gallbladder wall and distant surroundingtissues on the serous membrane side, that indicates strong adhesions with surroundingstructures against a background of pronounced inflammatory response in the area of thecystic duct and cystic artery ("infiltrative sclerotic" type). After 18 days followingendoscopic transpapillary interventions on the common bile duct signs of restoration ofthe structure of the gall bladder wall ("restorative" type of changes in the wall of the gallbladder) are observed.Conclusions. Standard therapy in preparation for the second stage of surgical treatmentof acute cholangitis in some cases does not restore the gallbladder wall and its strength,which is associated with varying degrees of inflammation, necrosis, atrophy, sclerosis ofthe gallbladder wall after endoscopic transpapillary intervention, as well as individualboth regenerative and immune capabilities. Changes in the gallbladder wall can bedescribed as changes in the "infiltrative sclerotic" and "restorative" types.

Classification of the cystic duct patterns and endoscopic transpapillary cannulation of the gallbladder to prevent post-ERCP cholecystitis

BackgroundEndoscopic transpapillary cannulation of the gallbladder is useful but challenging. This study aimed to investigate cystic duct anatomy patterns, which may guide cystic duct cannulation.MethodsA total of 226 patients who underwent endoscopic transpapillary cannulation of the gallbladder were analyzed retrospectively.ResultsAccording to the cystic duct take-off, 226 cystic duct patterns were divided into 3 patterns: Type I (193, 85.4%), located on the right and angled up; Type II (7, 3.1%), located on the right and angled down; and Type III (26, 11.5%), located on the left and angled up. Type I was further divided into three subtypes: Line type, S type (S1, not surrounding the common bile duct; S2, surrounding the common bile duct), and α type (α1, forward α; α2, reverse α). Types I and III cystic ducts were easier to be cannulated with a higher success rate (85.1 and 86.4%, respectively) compared with Type II cystic duct (75%) despite no statistically significant difference. The reasons for the failure of gallbladder cannulation included invisible cyst duct take-off, severe cyst duct stenosis, impacted stones in cyst duct or neck of the gallbladder, sharply angled cyst duct, and markedly dilated cyst duct with the tortuous valves of Heister.ConclusionClassification of cystic duct patterns was helpful in guiding endoscopic transpapillary gallbladder cannulation.

Problematic issues of endoscopic biliary stenting

Objective. To study the results of endoscopic biliary stenting (EBS) for biliary obstruction of various genesis to determine the problematic issues of the procedure and possibility of its efficacy raising.&#x0D; Materials and methods. Experience of conduction of 5748 endoscopic transpapillary interventions in 2010 - 2017 yrs was analyzed: endoscopic papillosphincterotomy was performed in 2919 (50.8%) observations, stenting of biliary ducts - in 379 (6.6%). In 296 (78.1%) observations plastic stents (PS) were introduced, while in 83 (21.9%) – the self-expanding metallic stents.&#x0D; Results. Of 208 patients, in whom primary temporary EBS was performed for tumoral biliary obstruction, using PS, in 153 (73.6%) the next stage of treatment have constituted elective operation in 10 - 14 days after elimination of hyperbilirubinemia, signs of cholangitis, additional examination and determination of the intervention volume. Among these patients in 56 (36.6%) radical operations were performed, and in 97 (63.4%) – palliative operations. In 47 patients PS for closure of external biliary fistula (EBS) PS was introduced: in 13 (27.7%) – for tubular stenosis of distal part of common biliary duct, in 7 (14.9%) – for insufficiency of sutures of common biliary duct (after choledocholithotomy), in 14 (29.8%) – for intraoperative damages of extrahepatic biliary ducts, in 5 (10.6%) – for presence of Luschka channels, in 8 (17.0%) – for a state after hepatic resection, echinococectomy. Presence of concrements, which due to some reasons were not removed endocopically, in environment of purulent cholangitis have constituted the indication for performance of EBS in 24 (8.1%) observations, chronic pancreatitis, complicated by obturation jaundice – in 9 (3.0%). Correction of iatrogenic damages of biliary ducts with development of their partial strictures, EBF, using EBS with introduction of PS, were performed in 8 (2.7%) patients.&#x0D; Conclusion. The necessity exists to study the treatment results in patients, suffering biliary obstruction of various genesis, to determine problematic issues of the main procedures and possibilities of their efficacy raising.

Gall Bladder Drainage for Acute Cholecystitis in Surgically Unfit Patients: Endoscopic Ultrasound Guided Transmural Drainage or Endoscopic Transpapillary Drainage!

AbstractAcute cholecystitis (AC) is a potentially serious condition that is associated with significant morbidity and mortality. Laparoscopic cholecystectomy is the treatment of choice of AC in surgically fit candidates. However, high-risk surgical patients with AC are a therapeutic dilemma. Various alternative treatment options available include percutaneous transhepatic cholecystostomy (PTC), endoscopic ultrasound (EUS)-guided gall bladder (GB) drainage or endoscopic transpapillary drainage of GB. Due to higher complication, unplanned hospital readmission rate, risk of tube dislodgement, and high risk of recurrent acute cholecystitis associated with PTC, endoscopic drainage GB is the preferred, minimally invasive treatment option. Both endoscopic transpapillary GB drainage as well as EUS-guided transmural drainage of GB are effective GB drainage options, but both of them have not been compared in terms of their efficacy and safety. In this news and views, we have discussed two interesting articles which have compared EUS-guided GB drainage and endoscopic transpapillary drainage.

Acute carcinomatous pancreatitis in patients with pancreatic head cancer complicated by obstructive jaundice

The aim — to improve the diagnostic and surgical palliative treatment results in patients with unresectable pancreatic head cancer, complicated by obstructive jaundice with the canceromatous pancreatitis.Materials and methods. A comparative analysis of the various surgical techniques aimed on the bile duct obstruction syndrome correction by biliodigestive shunting in the palliative surgical treatment of patients with unresectable pancreatic head cancer and mechanical jaundice was done. The analysis of the archival material (1st group, n = 155) was performed at the first stage. It was established that although the pancreatic tumour causes obstruction of both the common bile duct and the main pancreatic duct, however, mechanical jaundice was developed in all patients, and obstructive canceromatous pancreatitis only in 8.8 % of patients. The mild forms of pancreatitis were effectively eliminated by routine methods of intensive care. However, in cases of moderate severe pancreatitis (according to the Atlanta‑92 classification, third revision), the state of patients’ health progressively deteriorated, as the mechanical jaundice background developed a life‑threatening multiorgan failure and the biliodigestive bypassing was not sufficient to avoid a postoperative complications and unsatisfactory results in all cases. Based on the obtained results analysis it was concluded that modernization is need to both surgical tactics and techniques in such patients. Therefore, it was planned and carried out original trial with the optimized treating technology approbation for such patients. To this end, 112 patients with pancreatic head cancer, complicated by mechanical jaundice (Group 2), treated in the surgical department for the period of 2007 — 2018 were included in an open, prospective, randomized study.An approbation of the original algorithm for the carcinomatous pancreatitis verification was performed; the effectiveness evaluation of the proposed tactics and the technique of surgical treatment, including the developed method of combined bilio‑ and pancreaticodigestive bypass surgery was done.Results and discussion. The safety and clinical efficacy of simultaneous with biliodigestive pancreatodigestive bypass was established in patients with locally advanced pancreatic head cancer complicated by obstructive jaundice and carcinomatous pancreatitis. The tactics of a two‑stage surgical treatment was described, which involves first performing external cholangiostomy with minimally invasive techniques or endoscopic transpapillary stenting in patients with signs of liver failure or carcinomatosis pancreatitis, and then the main stage of surgical intervention.Conclusions. The proposed tactics of two‑stage surgical treatment in patients with nonresectable pancreatic head cancer complicated by mechanical jaundice and pancreatic cancer, which includes a two stage technology of surgical interventions with the use of minimally invasive operations in the first stage of treatment and one‑step combined bilio‑ and pancreaticodigestive bypass surgery on the second one, contributes to the reduction of postoperative complications, mortality and improves the patients’ life quality.

Current approaches to the treatment of complications of endoscopic transpapillary interventions

Objective. Retrospective analysis of the treatment of complications after endoscopic retrograde transpapillary interventions. Material and methods. There were 5701 endoscopic retrograde interventions for the period from 01.01.2008 to 01.01.2019. Overall incidence of complications was 1.5%, mortality rate – 0.24%. Bleeding after endoscopic papillosphincterotomy developed in 13 (0.22%) cases, acute postoperative pancreatitis in 49 (10.85%) cases, ERCPassociated perforation in 24 (0.42%) patients. Results. Endoscopic approach (epinephrine injection into the edges of major duodenal papilla and cautery) was usually effective for bleeding after endoscopic retrograde cholangiopancreatography. Massive intraoperative bleeding required surgical treatment in one case with favorable outcome. There were no cases of recurrent bleeding. One patient died due to severe bleeding in 3 days after surgery. ERСP-associated (“retroduodenal”) perforation occurred in 24 (0.42%) patients. Endoscopic treatment was undertaken in 16 cases and was effective in 15 (93.75%) cases. Overall mortality among patients with ERCP-induced perforation was 20.8%. An attempt of pancreatic duct stenting for postoperative pancreatitis was made in 30 cases; successful procedure was in 28 (93.3%) cases. Surgery resulted recovery in 26 (86.7%) patients. Progression of acute postoperative pancreatitis followed by death occurred in 2 cases despite successful pancreatic duct stenting. Mortality rate was 25%. Conclusion. Treatment of ERCP-associated complication is lengthy, time-consuming and expensive. Timely diagnosis and assessment of severity of complications is essential. It is necessary to determine an adequate surgical approach. Everyone should keep in mind all possible risk factors, clearly define the indications for ERCP and follow the technique of the procedure strictly in order to reduce complication rate. In our opinion, endoscopic approach is advisable for post-ERCP complications, because conventional surgery results higher postoperative mortality, increased duration and cost of treatment.

Retrograde minimally invasive technologies in the treatment of obstructive jaundice syndrome

Approaches and results of endoscopic transpapillary procedures in the treatment of patients with obstructive jaundice of various origins are analyzed. Modern trends in the development of endobiliary surgery and recommendations devoted to various endoscopic techniques and methods of biliary decompression depending on etiology and severity of obstructive jaundice, management of patients and dates of interventions are described. Leading specialized centers are characterized by quite high effectiveness of endoscopic transpapillary interventions in patients with cholelithiasis complicated by obstructive jaundice (95.2–97.5%), benign biliary strictures (63.7–92.8%) and biliopancreatoduodenal malignancies (70–96.8%). Analysis of modern tactical and technical approaches and international guidelines for transpapillary interventions allowed us to determine the current capabilities of retrograde minimally invasive curative technologies, systematize and optimize the basic algorithms for endoscopic care in patients with obstructive jaundice, and outline the prospects for the introduction and improvement of the effectiveness of new techniques.

Surgical Treatment for Septic Complications in Patients with Duodenal Perforation Following Endoscopic Retrograde Transpapillary Interventions

Background The most severe clinical cases following transpapillary endoscopic interventions are duodenal perforation with damage to the common bile duct and pancreatic duct, entrance into the abdominal cavity and retroperitoneum the aggressive contents of intestine and the infections. They usually lead to higher mortality. Aim Evaluation of the optimal management for duodenal perforation in patients who have undergone transpapillary endoscopic interventions. Material and Methods A retrospective analysis of surgical treatment in thirty-two patients with duodenal perforation after transpapillary endoscopic interventions from the year 2007 to 2018 in one center was carried out. Nineteen cases (59.4%) were diagnosed less than 24 hours, 13 (40.6%) – more than 24 hours after injury. Twenty patients had the primary reconstruction of duodenum with various drainage options of injury area. In 19 cases there were a two-stage surgical procedure according the original method: 12 had a primary surgery, 7 were reoperated. Results After primary reconstruction of duodenum 11 patients (55.0%) had complications, seven (63.6%) – were re-operated, in four we have applied efferent treatments and symptomatic therapy. Three patients (15.8%) died. After two-stage surgery procedure 7 patients (36.8%) had surgical complications, five (26.3%) – were re-operated. Three patients (15.8%) – were died. Conclusion Primary duodenum reconstruction can be performed if the injury occurred less than 24 hours before surgery. Two-staged surgery is justified in cases with purulent inflammation in abdominum and reproperitoneal cavity because procedure allows reducing mortality from abdominal sepsis

Successful treatment of pancreatic fistula for reconstructing the intestinal tract with endoscopic transpapillary drainage: A case report

Successful treatment of pancreatic fistula for reconstructing the intestinal tract with endoscopic transpapillary drainage: A case report